


A Crash Course in Intensive Care for (Sherlock) Fic Authors

by J_Baillier



Category: Sherlock (TV)
Genre: Comment Fic, Fic Meta, Gen, Hospitalization, Hospitals, Illnesses, Intensive care, Major Character Injury, Major Illness, Medicine, Sickfic, Writing, Writing Meta, critical care - Freeform
Language: English
Status: In-Progress
Published: 2017-05-08
Updated: 2017-05-09
Packaged: 2018-10-29 12:35:28
Rating: Not Rated
Warnings: No Archive Warnings Apply
Chapters: 10
Words: 10,142
Publisher: archiveofourown.org
Story URL: https://archiveofourown.org/works/10854126
Author URL: https://archiveofourown.org/users/J_Baillier/pseuds/J_Baillier
Summary: A general introduction to the pitfalls and possibilities of depicting intensive care in fic.





	1. Introduction and some important general issues

**INTRODUCTION**

I have been very positively surprised countless of times how well the non-medical professional fic authors in our fandom have tackled the technicalities of medical science. However, several very understandable misconceptions, clichés, stereotypes and false assumptions keep popping up. Most of them are due to the fact that someone who hasn't worked at an ITU can't reasonably be assumed to know these things, and some stuff can easily be blamed on TV and movies. I hope that this (incompletely, subjective, polemic and hopefully even slightly amusing) list of observations is of use to fellow authors. I'm happy to answer questions, so keep 'em coming. On the side of sharing information, I'm going to be mentioning Sherlock fics in which certain subject matters are discussed. If someone wishes to see a very well-done depiction of intensive care, I'd recommend watching season three of TV drama _The Fall_.

Before we begin, I want to say this: even though I rant and rave don't worry about the details and getting everything right. When I read Sherlock stories, I easily forgive even big blunders by non-medpro authors. Not your division. If you tell me a lovely story, I won't care if you mix your CVCs with your FBCs.

 

**DISCLAIMER**

This is not a medical textbook. Many things have been simplified and corners cut. The purpose of this is to provide ideas and resources for writers of fanfic, not medical advice.

Medical practices vary between countries and even hospitals within the same country. Terminology varies in the same manner. I try to stick with UK versions, which is kind of a bummer for me, since I live and work and was medically educated in Scandinavia. If a UK professional finds an issue with something here, please drop me a note so we can improve on this together. Also, while my medical licence says that I'm a Specialist Consultant in Anaesthesiology & Intensive Care, my days as an intensivist are over and it is most decidedly not my subspecialty or my strongest suit within this specialty. As a final word: this was written for the purposes of fic research, not as medical advice for actual patients. This is thus not a complete list of _everything_ that happens to people at ITUs and does not apply to all possible cases. What this is, is a list of possibilities. Think of it as a smorgasboard of potential medical H &C. What you're writing is fic, not an information leaflet. I'm trying to give your imagination wings, not cut off its legs. If something here catches your fancy, do some googling. Many people have explained these things in more detail (and probably better than me).

Those who have read my stories know that I do not make light of serious things in them. Here, however, I will try to keep the tone light enough since we are not talking about individual patients, fictional _or_ real. Intensive care is an intense, dynamic, fast developing and emotionally demanding field of medicine, and I have the utmost respect for those of my colleagues who have chosen it as their path.

That being said, let's crack on!

 

* * *

 

 

**SOME MISCELLANIOUS GENERAL ISSUES ABOUT INTENSIVE CARE**

 

**Which patients need to bed an an intensive care unit (ICU/ITU)?**

Intake criteria can vary, but the main principle is that patients who have a severe disturbance in one or two organ systems need to be at an ITU. A regular bed ward usually doesn't hook patients up to continuous monitoring, and they can't spare a nurse to sit by every patient's bedside. If a patient needs constant watching over, for instance if they're delirious and in need of sedation, they might also end up at an ITU. Some patients might not have a severe organ dysfunction _yet_ , but they're at a risk of developing one. Examples: epiglottitis threatening to close down a patient's airway, an internal organ injury that looks like it could be just observed while it limits itself, but needs to be monitored in case there's a sudden rupture. Anyone who needs to be hooked up to a respirator usually goes to the ITU. Anyone who acutely needs dialysis usually taken into the ITU. To summarise: all the severely injured and critically ill patients go to the ITU.

One thing that often seems to baffle writers for fic, original fiction and TV and movies are altered states of consciousness. The general rule is this: if a patient's [Glasgow Coma Scale](https://en.wikipedia.org/wiki/Glasgow_Coma_Scale) is below a certain level (usually 9), their airways need to be secured to protect them from aspirating stomach contents and to control their carbon dioxide levels. Regardless of the reason for being out of it, if someone is unconscious _enough_ , they can't be assumed to look after their own breathing and/or not inhale their own vomit. They need an intubation tube down their throat, and that also means that they need to be hooked up to a respirator. 

Not all critically ill patients will be admitted to the ITU. Often, the decision is brutally hard to make. The patient's chances of recovery from their current illness is largely dictated by their health prior to them contracting their current injury or illness. Age is not the sole deciding factor. Hopeless cases do not belong at ITUs. The number of spots at the ITU are not limitless; they need to be given those who will benefit from them. It is also unethical to prolong someone's suffering with intensive care, if there is no hope of recovery.

[Here's a nice, detailed article](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1115908/pdf/1544.pdf) on how to select patients to be admitted. [Here's a flowchart](http://www.londonccn.nhs.uk/_store/documents/2016-admissions-flowchart.pdf) from a London hospital that helps with such decision-making.  
  
  

**What sorts of doctors work at an ITU?**

This varies. In some units, anaesthetists/anaesthesiologists run the ITUs and the other docs just act as consultants. At some units, a pulmonologist/respiratory therapists sorts out their turf, but the consultants from different specialties handle the rest of patient care. At some ITUs, anaesthetists and internists (or some other specialists, depending on whatever sort of an ITU is in question) work together to run the unit.

There are many sorts of ITUs. Some are generalised ones, where you might find all kinds of patients from head injuries to diabetic ketoacidosis. Some ITUs are just for surgical/trauma patients, some of just for neurological and neurosurgical patients. Kids usually get their own ITUs and so do neonates. Pick whatever option suits your story best, or have a look at a suitable hospital's website. They usually give some general idea on what sorts of patients each ITU unit handles. This largely also dictates what kinds of doctors work there.

 

**What other staff does an ITU require to function?**

Never forget that an ITU would instantly crumble without a legion of other (medical) professionals! Nurses, physical therapists, technicians, IT experts, laboratory technicians, pharmacology experts, cleaning and other maintenance personnel, imaging technicians/radiology nurses…

There are patient care assistants/ nursing assistants who help with moving and washing patients among other things. Quoting a commenter: "Depending on the nature of the ICU and the patients cared for there, there may also be a 'turn team' who will assist in the rolling of patients for pressure area care (PAC - it even has its own chart in the record in a lot of hospitals). Patients with spinal injuries or significantly difficult to manage injuries/ multiple drains or the like will need several pairs of hands to log roll/ wash/ change/ moisturise them safely and you cannot pull all the ICU nurses at once to do this." 

 

  
      

**The downsides and risks of intensive care**

Intensive care is invasive and risky business. While it can save lives and limbs, its very nature also creates risks for complications.

Prolonged bed rest, infections and many others factors present in this patient population give them a heightened risk of blood clots. They're often injected with blood thinners, or if that isn't possible, then pump socks or some other similar system is used.

Patients on a respirator are at risk of ventilator-associated pneumonia. All the other cannulas and hoses running into their bodies carry a risk of introducing bacteria into their bladder, their bloodstream or wherever than hose goes into. A respirator is never as good and natural a manner of breathing as what the patient does themselves with their own muscles and lungs. Bits of lung sacks might collapse due to not being inflated enough. A respirator might blow up the patient's lungs a bit too heavily, stretching the lung structures and causing microdamage.

Patients who need intensive care for a long time will lose muscle mass and joint flexibility. They are at risk of developing things such as intensive care polyneuropathy, intensive care myopathy and post-intensive care syndrome.

Intensive care poses a risk for developing a stress ulcer in the stomach or the small intestine. There are medications that can be used to prevent this. In Kourion's [Shadow Child](http://archiveofourown.org/works/1048030), a very complicated stomach ulcer is what lands Sherlock in the hospital and in emergency surgery.

Getting really ill is a big crisis for the patient and their loved ones (admit it: this is part of why you're writing about it, because of course it is, why else would we want to get one of our characters stuck at an ITU if it weren't for the _angst_ of it?). That crisis doesn't end when they're carted off to a regular ward. Particularly those patients who have needed intensive care for a long time and who have been conscious at least for some of the time are at risk for an acute traumatic crisis reaction, even PTSD.

Even during an ITU stay, patients might experience a lot of psychological problems. ITU delirium is a major issue, and it doesn't always present as active restlessness.

 

**What if a patient at the ITU is not getting better?**

If the situation is judged to be medically hopeless, care will be withdrawn. It is not humane to keep patient suspended between life and death if there is no hope of reasonable recovery. Often the solution is to create a tracheostomy which will allow the patient to be moved to a regular ward. All the treatments that help them feel comfortable will be continued, but stuff associated with intensive care will be ceased. Antibiotics for a new infection might not be given anymore. Surgery will not be undertaken. Death is allowed to happen. Often that happens at the ITU, since these patients are often so critically ill that withdrawing some measures of care will result in their demise quickly. Some patients will live for days or weeks after being transferred out of the ITU. The decision-making in this sort of a situation is case-based and individualised and the wishes of the patient and their loved ones need to be taken into consideration.

I really liked the way the decision-making process and the associated extreme anxiety it causes all involved was discussed in [Raison D'Etre](http://archiveofourown.org/works/1141383) by AmphigoricSymphony & DemonicSymphony.

      

 

**What kinds of surgical patients are taken to the ITU from the operating room?**

In general: patients who have just had cardiac surgery, major neurosurgery, major emergency surgery whether that be for trauma, abdominal organ disaster or something else equally severe. Patients who have had a major complication during surgery such as major bleed or anaphylaxis. Patients who were very ill before surgery and continue to be that way.

There are some situations in which interventional radiologists (ie imaging doctors trained to do procedures such as fixing brain aneurysms by slithering in stents and other nifty things through the patient's vascular system) can do wonders, but for acutely life-threatening surgery the trend tends to be that the procedures are not done via small scope holes. When you gotta go, you make a properly big opening. That's why the small dressing we saw on Sherlock in HLV was impossible. He coded, likely from a massive lung or heart injury or injury to a major blood vessel. When that happens, the chest needs to be cracked open properly. If you're not squeamish, do a google image search for "thoracotomy wound" and you'll see what I mean. The suffix –otomy point to a major opening somewhere in the body. A laparotomy is where you open up the stomach if, for instance, the abdominal aorta has ruptured or a patient's bowel has twisted around itself. The suffix –ostomy point to a minor incision into the body, most often for a drain.

A craniotomy is what you do if the brain needs to be operated on. That might be needed for a tumour, a major ongoing bleed or something else that can be taken away to fix the rising pressure inside the skull. A brain aneurysm might also require open surgery if the radiologists can't fix it. This is what Sherlock underwent in [The Road of Bones](http://archiveofourown.org/works/4527585), and craniotomies are what he _does_ with John in the [You Go To My Head series](http://archiveofourown.org/series/392395).

If the brain is critically swollen, and nothing else helps, a decompressive craniectomy might be undertaken. It means cutting out a section of the patient's bony skull to relieve pressure.

    

**Worst cliché pet peeves seen in TV and movies and books (and yes, fic) when it comes to intensive care?**

  * patients normally ineligible for ITUs being taken in
  * permanent coma patients "living their lives" at an ITU
  * prolonged intubation with no consideration for a tracheostomy
  * deeply unconscious patients without secured airways
  * critically ill or injured ITU patients without an arterial line and with just one smallish regular IV
  * the sound of the respirator being heard in the background when the patient isn't hooked up to one, or the respirator monitor shows curves in this situation
  * stuff on the monitor that isn't being monitored
  * saline and oxygen as cure-alls for everything
  * old-fashioned x-ray boxes - imaging is all digital nowadays (nearly everywhere)
  * the fact that they gave Sherlock a morphine infusion in a regular infusor pump in HLV; it probably took him about 3,4 seconds to figure out how to adjust the settings (I doubt even a number code locked PCA [patient-controlled analgesia] pump would have stopped him, but at least it would have shows some effort in not giving an addict effectively free rein with their opiates... I poked some gentle fun at this in [Lunar Landscapes](http://archiveofourown.org/works/5993508)
  * tiny wounds and dressing after an injury or other emergency necessitating major emergency surgery that would invariably mean a big wound  
  
 



**Taking a trip with an ITU patient**

ITU patients might need to be taken to the operating room, to the radiology suite or even to another hospital. This requires packing up all meds you might need to administer, making sure everything is taped nicely into place (especially the intubation tube – don't want to be reintubating someone in a moving ambulance on the motorway!) and making sure the infusor pumps have enough stuff for the duration of the trip.

You will also need a portable respirator and an oxygen bottle to hook up to it. And, you need something to keep the patient warm (especially in the Scandinavian winter…). And, you need enough manpower to help you out. A driver, a nurse and a doctor are a minimum for transporting a patient on a respirator.

[An example](https://www.draeger.com/Products/Image/oxylog-3000-plus-img-D-9219.jpg) of a portable respirator.

 

**Are there lots of private rooms available at ITUs?**

Not in most places. It's handier for the nurses to be able to keep an eye on each other's patients and help one another out. In general, ITU private rooms are for patients who need to be isolated because of an infection or because they're at risk of getting one. Burn units might have private rooms for the more severe cases to enable climate control.

I've yet to see a fic where they put Sherlock in a regular, several-patients' ITU room. This is fine. I'm sure Mycroft made some calls and got him that private room.

The nurses might well leave him alone in the room with John for a while, but likely not with someone who has no medical training. There would be a nurse in the room with him all the time otherwise. This reality was something I had to get creative to circumvent in [The Breaking Wheel](http://archiveofourown.org/works/7724449/chapters/17605366).  
  
  
  
**Would John be allowed to weigh in on the medical decision-making of a friend or family member at the ITU?**

Not outside the capacity of a trusted friend or family member. Doctors in the UK are not allowed to treat or prescribe medications to people close to them. This is a rule I have, however, bent in my writing. [Harmless Things](http://archiveofourown.org/works/4750349?view_full_work=true) is a good example of a situation in which John's role easily extends beyond the norm. Early in [The Breaking Wheel](http://archiveofourown.org/works/7724449?view_full_work=true), John argues with an A&E doctor on who should deliver Sherlock some devastating news.

 

 


	2. Breathing is boring (or not)

**Explain all this respirator business, please?**

A respirator is a machine that either breathes for a patient, or helps them do it. A respirator is usually hooked up to an intubation tube, which is a plastic thingy that reaches into the patient's trachea. It usually has an air-filled cuff (a balloon-like thing around the tube) that prevents blood, vomit and other stuff from getting into the patient's lungs.

It's usually ideal if a patient does at least some of the breathing themselves. Modern respirators can recognise and aid the patient's own breathing.

A patient may need to be intubated at the ITU for many different reasons. They include but are not limited to: having had surgery that causes swelling in the airways, having had major surgery and the doctors want to wean them off a respirator slowly and they don't want to keep the patient in the OR unit for an extended period of time, the patient has an injury in their airways or lungs or somewhere close that might compromise the airway, the patient is unconscious (either due to illness or injury, or so heavily sedated that their airways need securing), the patient is so severely ill that their lungs or chest muscles or diaphragm have stopped working properly.  

A generalisation: any severe illness can mess the body up to such an extent that the patient has no energy for breathing. Sepsis is a good example.

When a patient begins to try to breathe on their own or is allowed to start doing so and/because their illness is getting better, weaning off from the respirator can start. At first, the patient gets help from the machine, which might draw occasional breaths for them. When their own breathing improves, the machine will programmed to give them less and less help. When an ITU doctor or an anaesthetist judges them to be ready, the breathing tube is removed (ie the patient is extubated). After this, they need to be monitored even more closely than usual to catch on if they weren't ready t be weaned off, after all, or if their illness takes a turn for the worse. It's not unheard of to have to intubate the patient again after a while.

Not all patients who need support for their breathing will need to be intubated. There are different sorts of breathing support treatments which can be used on awake patients which can spare them from having to be intubated. These are collectively referred to as non-invasive ventilation, and the main options are CPAP and BiPAP. [Here are some jargony details](https://lifeinthefastlane.com/ccc/non-invasive-ventilation-niv/). My story [Harmless Things](http://archiveofourown.org/works/4750349?view_full_work=true) features non-invasive ventilation.

A nasal cannula or an oxygen mask are the commonest ways in which to administer O2. There's also a thing called high-flow oxygen treatment (again, this is for those wanting to be really fancy) which can be used with awake patients through, for instance, a specialised nose outlet.

 

**What about oxygen? Ain't it a nifty cure-all?**

Nope. Too much oxygen can even be harmful.

Whether giving oxygen is beneficial depends on what the patient's problem is. It's often a good thing to do in an emergency, but after that the nature of the problem needs to be deduced. Are they lacking oxygen, or is the problem that they're too unconscious, injured or exhausted to muster up the strength to breathe enough? Oxygen might help with the former, but the reason for the lack naturally needs to be investigated. In the latter, oxygen might help a bit, but the mechanical problem is the one that needs to be sorted out.

So, by all means do slap on that oxygen mask, but be aware that while it buys time, it is often not a solution to the actual problem.

 

**Explain this intubation business, please? Also, what's all a tracheostomy and why might one be needed?**

As  explained above, many patients at the ITU are intubated. While the procedure of inserting an intubation tube into the patient is often a fast and easy thing to do, it can also be a risky procedure. Unless there's an emergency, this is something that needs to be planned and risk-assessed. It requires training to be able to do reliably, and most doctors aren't very well-versed in the procedure. Docs and other people who can be expected to be able to wield the laryngoscope (the metallic contraption used to pave way for the tube past the tongue and other stuff that's in someone's throat) are: emergency physicians, intensivists/ITU doctors, some EMTs in some countries, and anaesthesiologists. For really difficult intubations you'd want an anaesthesiologist (or sometimes an otorhinolaryngologist ie an ear-nose-throat doc, because they are often wizards with special airway equipment).

If there wasn't someone better trained available, any doctor could probably be expected to have a try at intubating. John probably has a bit more training in it than your average surgeon, since he's been an army doc. He could do it in an average case.

At an ITU it would probably be an anaesthesiologist or an intensive care specialist (who often are anaesthesiologists) who would perform the intubation. 

General rule: only utterly lifeless people being resuscitated should be intubated without giving them any medications before it. Even unconscious people's bodies can react to intubation in ways that can harm their suffering brains, unless you give them something to make them more comfortable. Why, you ask? Well, imagine someone shoving a soup ladle into your throat and them advancing a huge drinking straw into your windpipe, which will make you want to cough like _mad_. That's why.

When intubating someone, here's what we usually give them: something for the pain (usually fentanyl or some other opioid), something to knock them out (propofol as made famous by Michael Jackson, sodium pentothal, ethomidate or a benzodiazepine) and something to relax their muscles (such as rocuronium or suxamethone). In the battlefield, you can make do with just ketamine if you need to sort all this out with one drug especially if you've got no IV connection, but it's hardly ideal. Doable, but not ideal (I speak from experience).

It's not good to be intubated for a long time. If there's a need for that, a tracheostomy needs to be considered. It will bother the patient less than an intubation tube (which means less need for sedation), allows them to eat and to talk and doesn't pose the risk for vocal chord and other sorts of damage that prolonged intubation can cause. A tracheostomy is a hole made through the neck into the trachea, where a cannula is then inserted, through which respirator treatment can continue. The patient can also be suctioned through the tube (very unpleasant for an awake patient). 

[Sherlock intubated](http://kissthemgoodbye.net/sherlock/displayimage.php?album=13&pid=43493#top_display_media) in HLV. It warms my hear to see that they had secured the tube in place, even taping/tying it down as low as possible, which is the correct way to do it. The blue, narrow hose attached to the tube goes to the air-filled cuff. The thing sticking out of the left side of his mouth looks like the opposite end of the ribbon/tape used to tie the tube in place.

Here's [a Youtube video of an intubation](https://www.youtube.com/watch?v=OTe9TauBNSg) carried out. In it, a regular Macintosh laryngoscope is used to visualise the patient's vocal cords. If this fails to produce a nice view, a videolaryngoscope or a thin, fiberoptic scope might be used instead or next.   
  
The reasoning for when patients need to be intubated was explained under the question pertaining to which patients belong in the ITU. In 7PercentSolution's [Musgrave Blaze](http://archiveofourown.org/works/5722405) Sherlock breaks a bone but ends up intubated, because.... Well, I don't want to spoil the fun but I have to commend the medical realism of the decision-making there regarding the need to intubate. 

 

**What are all the things that can go wrong with a patient's lungs?**

There's no way this list could ever be comprehensive, but I'll try to list the major issues affecting patients at the ITU.

  * pneumonia, ie an infection in the lung/lungs caused by a bacteria, a virus or a fungus (what they might catch depends on the patient's health prior to the infection)
  * atelectasis ie incomplete aeration of some parts of the lung due to collapsed lung sacks; a common problem with patients on a respirator
  * severe asthma attack
  * an exacerbation of some other underlying lung disease such as chronic obstructive pulmonary disease (COPD)
  * [ARDS ie adult respiratory distress syndrome](http://www.mayoclinic.org/diseases-conditions/ards/home/ovc-20318589)
  * inhalational lung injury due to inhaled toxins
  * blunt of sharp trauma such a getting shot
  * chylus fluid, blood or air in the pleural cavity (due to spontaneous burst of an air sack in the lungs of trauma); blood in the cavity is called a hemothorax, air a pneumothorax, chylus a chylothorax... You can also have a combination such as a hemopneumothorax
  * too much pleural fluid in the pleural cavity (tons of things can cause this)
  * a tumour in the lungs, in the airways or somewhere close pressing down on the lungs



 


	3. Blood and fluids and medications

**What sorts of medications do patients at an ITU typically need?**

Depends on the illness, but there are some common stuff many will end up getting.

  * Antibiotics, if they're got sepsis or some other sort of infection
  * Something to prevent stress ulcers
  * Sedatives
  * stuff to give help gastrointestinal system a bit of a boost since it tends to get a bit stunned and lazy at the ITU, ie some kinds of laxatives
  * Pain medications (usually some sort of an intravenous opioid such as morphine)
  * Specific medications to treat the reason the patient is at the ITU
  * Paracetamol or something in that vein to treat fever
  * Inhalational medications if the patient has a lung problem necessitating them



 

**How are medications and fluids given to patients at the ITU?**

Most medications are given intravenously as either regular short(ish) infusions or continuous infusions. Fluids are often given as continuous infusions, either from a free-dripping bag or through an infusor pump that keeps a steady rate. Sedatives are often continuous infusions, as are stuff given to support the patient's blood pressure. Medications for pain can be continuous or given from the syringe as a quick injection (also called a bolus).

Tablets can be crushed and fed through the NGT. Some stuff is sometimes administered through the rectum such as laxatives, ion exchanger resin and benzodiazepines.

 

Stuff a lot of patients generally end up needing when staying at an ITU:

  * fluids
  * nutrition
  * pain medication
  * sedative infusion ie something to make them calm/sleep
  * continuous infusion of insulin to control blood sugar
  * diuretics to control fluid leaving the body
  * something to prevent stress ulcers
  * something to jog their bowels



 

**Nutrition at the ITU**

Some patients at the ITU who are awake might be allowed to eat normal food. Patients who can't will probably be managed on clear fluids (and blood products, if need be) for a few days, but after that body tissue breakdown will need to be limited by starting them on enteral or parenteral nutrition. That means giving them specially designed liquids either through a nasogastric tube or intravenously. Enteral ie through the intestines is always the more preferable option – it helps keep the guts functioning. If the patient's gastrointestinal system can't cut it at the moment, then intravenous is the only option. That stuff irritates smaller veins, so a central line will usually soon be needed. As soon as possible, intravenous nutrition should be swapped for enteral feeding. The enteral/intravenous solutions will contain a certain amount of fluid, but some additional fluid needs to be given in the form in intravenous infusions.

  
  
**What fluids does one assign to a patient?**

A detailed explanation would take up shelves and shelves of books. A simple general rule is this: fill their basic needs with a balanced solution (balanced means that it contains electrolytes and buffers and all sort of nice stuff as opposed to just sodium and chloride which is what normal saline has), add glucose as much as needed (some fluids contain this), and if the patient has lost or is losing or needs something in particular, give that in addition, such as extra potassium or sodium. Ringer's/Hartmann's solution is another common general solution fluid. Saline should not be used automatically. As already stated, fluid therapy is the fodder of endless medical arguments and schools of thinking. If in doubt, just call it IV fluid and you'll be fine. Just, please, not normal saline unless that is _precisely_ what the patient needs or there's nothing better available.

 

**When do patients get blood products and how are they selected?**

Whole blood is available in some areas, but nowadays separate products of red blood cells (RBCs), platelet (ie thrombocytes) and plasma (usually fresh frozen plasma, combined from several donors) are used in ratios that are selected depending on the patient's individual needs.

General idea:

  * Small bleed: clear fluids, maybe RBCs
  * Medium bleed or fast bleed: clear fluids, RBCs, fresh frozen plasma (FFP)
  * Big bleed or very very fast bleed threatening to become one: clear fluids, RBCs, FFP, thrombocytes (platelets), fibrinogen, tranexamic acid (a drug that prevents already formed clots from disintegrating), concentrates of specific clotting factors, calcium, controlling the hyperkalemia and acidosis and the patient's temperature which can often be associated problems in big bleeds



Hemoglobin (the amount of red blood cells in the blood) can be measured quickly, as can some parts of the clotting cascade, but with certain things such as thrombocytes you often have to just make a general estimate on the direness of the situation and the amount of blood loss so far and decide based on that whether to order them.

FFP takes about half an hour to melt (hence the name fresh FROZEN plasma), so if it's needed, order in as soon as possible.

A word of warning about clear fluids: they can dilute the clotting factors in the patient's blood, which is in why you'd want to avoid giving too much of them in a significant bleed. 

An anaemia that has come about slowly does NOT usually require remedying with RBCs unless it's very severe and the patient is acutely symptomatic.

In an emergency, hospitals give patients 0 negative blood which is usually safe for everybody, but as soon as possible they'll try to swap to blood that has been matched to the patient's blood type. The ABO and rhesus properties are not the only things tested when cross-matching blood for a patient - there are many immunological factors that can cause an adverse reaction and only a set of the more common ones can be quickly tested.

 

**What sorts of adverse reactions can blood products cause?**

Perhaps the most important/common ones:

  * sepsis or some other infection from microbes in the donated blood (rare)
  * anaphylaxis and allergic reaction in the form of hives or fever
  * transfusion-related acute lung injury (TRALI)
  * hemolysis ie disintegration of red blood cells due to blood that wasn't a very good match for the patient



Here's [a more detailed article](http://www.healthline.com/health/transfusion-reaction-hemolytic#symptoms3) on the subject. And, [a concise article](http://www.mayoclinic.org/tests-procedures/blood-transfusion/basics/risks/prc-20021256) by the Mayo Clinic.


	4. The minutiae of daily life at an ITU

**Daily care routines at an ITU, aka the bedbath business**

Patients at an ITU need all the same stuff anyone does: food, drink, toilet stuff sorted out, bathing, exercise, something cerebrally stimulating to do unless they're comatose.

Patients at an ITU often can't shift their position to avoid getting bedsores and achy muscles. They need to be turned and moved often, and they need physical therapy to try to prevent losing muscle and joint movement. There are even specialised exercise bikes which can even be used by patients hooked up to respirators.

Toilet business at the ITU is sorted with urine catheters and diapers. Not what you'd find in a medically themed Mills&Boon book, that’s for sure…

Bed baths do happen. Not a nice substitute for a long, luxurious shower or a proper bath, but it's still something. Nurses will wash the hair or even patients on respirators and shave them. Hair will be combed and even styled, nails clipped, lotion massaged into hands and feet. Nurses are awesome. Respect the nurses. One purpose of one of my OCs, reader favourite ITU nurse Jonathan Baxter in the On Pins and Needles Series was to demonstrate that so isn't just the doctors who are important at an ITU. The docs may give many of the orders, but it's the nurses and other staff who make everything actually happen. He's based on a real-life awesome ITU nurse I know.   
  
Dental care is important at the ITU. When patients don't eat or drink and their mouths stay open because of the intubation tube, there will be lots of dental hygiene issues. Nurses will brush their teeth.

Some patients at an ITU will be awake. They'll need stuff to do. TV, books, company, pining for their army doctor…

 

**What are the visiting hours of ITUs?**

Depends entirely on the ITU. If a patient is doing really badly, these hours probably won't be enforced. On the other hand, too many visitors can exhaust intensive care patients. The nurses are in a big role to evaluate what benefits or doesn't benefit a particular patient.

Parents are often allowed to stay overnight with their children if the kid needs intensive care. I've yet to see an adult patient have an overnight visitor, but I see no reason why artistic licence couldn't be used to get John that mattress on the floor so that he can keep an eye on our consulting detective 24/7.

Visiting someone at the ITU can be a very upsetting experience. Not only is the visitor's loved one severely ill, they might also be hooked up to a lot of machines, lots of hoses and tubes coming out of them. They might be swollen or otherwise look very unusual. Many visitors don't linger long due to the patient being on the respirator, or because they feel uncomfortable in such alien surroundings. Nowadays patients are kept as lightly sedated as possible because it's beneficial to their recovery, so we try to remind visitors that even when they appear to be sleeping (and they're on the respirator) they can still hear and sense quite a lot of things. 

To some extent, a visitor being a medical professional will help with some aspects of the experience, but not with the emotional impact. They need and deserve to be treated as family members and not professionals on those moments. 

There are often rooms reserved for talking to family members available at the ITU, it's often a good place to start before the visitors are taken in to see the patient. In some situations, a guest room might be provided for a family member who has come from far away. Some hospitals do this, some don't.

 

**How are ITUs staffed outside regular office hours?**

There's going to be a doctor available at all hours within a moment's notice. Every patient usually has an assigned nurse around the clock. For awake, stable patients one nurse might look after a couple of them, but usually the patient-nurse ratio is 1-to-1.

The doctor covering the ITU outside office hours might not work there during the day so they might not be very intimately familiar with all the patients. They will have received a handover report from the previous person in charge of the patients, but any detailed and futurological discussions on the patients' bigger treatment goals should happen during office hours when the doctors who are really in charge of and familiar with those cases are available.

 

**Round and round the garden like a..... doctor at the ITU**

Most ITUs will have several rounds per day. Morning rounds, teaching rounds, rounds with surgeons, handover rounds with the doctors who are going to be on call... The times and practices vary, but a doctor looking after an ITU patient will probably see them many times a day.

 

**How many nurses per patient?**

Usually it's one per patient. If there are many patients who don't need very intensive care (are mostly at the ITU for monitoring after surgery without being on the respirator, for instance), one nurse might be able to take two, but generally it's 1:1. Many things done to patients on a respirator requires the help of several people, so nurses chip in to each other's business whenever needed, and relieve each other for breaks. **  
**

 

 

 


	5. Foggin' in the noggin' aka pain in the brain

**Are patients at the ITU given stuff to make them sleep, or are they unconscious, or….?**

It depends on why they've landed themselves at the ITU. If they don't need a respirator and are co-operative enough (ie they're not ripping out all their cannulas and hoses the minute they open their eyes), there's no reason to sedate them.

If they have a head injury or there's something else wrong in their brains (see separate section), it might be pertinent to keep them sedated to give their brains time to heal. Sedation means that the brain consumes less oxygen and nutrients, and sedation can help prevent seizures.

Extended sedation can also be used to give patients time to heal from surgery, or simply to allow their bodies to concentrate on getting better.

However, sedation doesn't mean that they're deep in slumberland. The less sedation is used, the less we see of some intensive care –related complications, and the easier it is to wean patients off the respirator. Unless there's an illness-based requirement for deep sedation/sleep, the aim is the have patients arousable, co-operating and calm. Modern sedative medications allow patients to breathe on their own and communicate with the staff while preventing pain and discomfort and even unpleasant memories.

Drug or alcohol withdrawal is common in trauma patients in particular. It puts a huge toll on a body already suffering from severe illness or injury. These patients often need to be sedated. They are also often rather resistant to sedative medications. (Yes, Sherlock, I'm definitely looking at _you_.) This is _not_ the time for deliberate detox or an AA meeting – someone who uses opioids, for instance, should receive upkeep treatment for their addiction to keep them from going into life-threateningly severe withdrawal, _and_ they need pain control on top of that. Just giving them what they normally use will not be enough to treat postoperative pain, for instance. The challenges of ITU pain control in patients such as Sherlock is discussed in my story [Lunar Landscapes.](http://archiveofourown.org/works/5993508)

[Here's a good article](http://www.nejm.org/doi/full/10.1056/NEJMra1208705#t=article) on sedation at the ITU, especially in connection to the next question.

 

**What are ITU delirium and ITU psychosis?**

Critical illness can mess with our perception and consciousness. ITUs are an alien environment where rest can be scarce, frightening things happen to a patient who can't understand what's going on, and circadian rhythms can get really messed up. [Here's an article](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2391269/pdf/cc6149.pdf) on the entity called ITU delirium, which means a state of acute confusion and cognitive impairment. It doesn't always manifest and restlessness and being combative - the so-called silent delirium is often underdiagnosed and can easily be as severe as the more active forms. [There is much still that needs to be learned](https://www.statnews.com/2016/10/14/icu-delirium-hospitals) about this issue.

[Here's a good list of the causes and risk factors](http://www.medicinenet.com/icu_psychosis/article.htm) of ITU delirium and psychosis. Such a thing developing does in no way require that a patient has had any psychological problems in their lives before they got ill. Sherlock develops ITU delirium in my story [The Breaking Wheel](http://archiveofourown.org/works/7724449/chapters/17605366).

[Here you can browse](http://www.icudelirium.org/patients.html) some good patient- and family-oriented materials related to these issues.

 

**General principles**

The brain is a vulnerable organ cradled in the safety of the skull. Sometimes, its bony cage becomes a problem, because it doesn't yield when there's extra stuff inside it such as a tumour, a bleed or swelling brain tissue due to injury, stroke or basically any reason that significantly endangers brain function. Too much stuff in a limited space means that the pressure inside starts to rise. There's no nice way to say this: if that pressure rises too much, the brain will herniate, ie squeeze out of the holes in the skull. This must be prevented or treated. Ways in which to do that:

  * Make sure blood doesn't pool into brain veins: don't let anything constrict the neck, raise the head of the bed
  * Regulate the level of carbon dioxide in the patient's blood, their blood glucose, their sodium levels and other things that alter how much blood circulates in the brain and how much fluid brain cells suck in
  * Keep the patient sedated to make their brain cells require less nutrients and oxygen
  * Prevent everything that might cause further harm such as seizures and fever
  * Make a hole in the skull if the pressure rises too much



How do ITU docs know how the pressure is behaving? There are physical signs to look out for, such as a patient's consciousness level dropping or their pupil size changing or their headache getting worse. If there is judged to be a need to monitor the intracranial (e inside-the-skull) pressure, an ICP meter might be installed. It means drilling a small hole into the patient's skull and threading in a small sensor. An important thing to remember is that it measures the pressure around _that_ spot. The swelling might vary in different areas of the brain. If the pressure rises a lot, then naturally the whole brain is in trouble, but small local changes are not representative of what's going on in, say, the opposite side of the brain.

I've yet to see a fic featuring brain injury where there's an ICP meter in place. It would be a nice touch, although it varies a lot from hospital to hospital how much this monitoring method is used.

Sedation breaks are used to evaluate patients with acute brain trouble. If computer tomography or magnetic images taken of their brains show a precarious situation with lots of swelling etc, sedation breaks might not be held, but usually they are a useful thing. The sedatives are stopped, and the patient monitored until they surface, or something a bit not good happens, such as a seizure.

[Here's a concise explanation](http://www.nhs.uk/conditions/intracranial-hypertension/Pages/Introduction.aspx) of elevated intracranial pressure.

 

**A study in seizures**

A seizure is an electric storm in the brain. There are many types of seizures from grand mal (which really can't be missed) to partial absence seizures which might even be unnoticeable to an outsider.

Seizures can be caused by many different things. [Here's a good list](http://www.healthline.com/symptom/seizures) of potential causes.

Seizures are treated with benzodiazepines, special antiepileptic medications (which can also be given regularly to prevent seizures) and, in dire cases, deep sedation. Prolonged seizures (also referred to as status epilepticus or epileptic status) are a life-threatening emergency.

If non-obvious seizures are suspected, the patient's EEG ("brain waves") can be monitored continuously, or a oneshot EEG taken to rule out ongoing seizure activity.

Partial absenze seizures escalating into grand mal as a side effect of a medication are featured in BeautifulFiction's [Electric Pink Hand Grenade](http://archiveofourown.org/works/442317). Epilepsy is a central feature in the [Carpe Diem series by Whitchry](https://www.fanfiction.net/s/8904679/1/Carpe-Diem)

 

 


	6. Let’s accessorise - all the hoses and cannulas and sundry

**The hoses and needles and catheters**

This is often the domain of the anaesthetist *enthusiastic grin*. In order to manipulate and monitor a patient's physiology and to treat their illness, lots and lots of devices and nifty little toys are needed. What is enough to monitor a stable patient for a minor operation in the OR will not be enough to monitor a critically ill patient at the ITU.

Here's a basic package of what a patient under intensive care usually gets:

  * continuous ECG (electrocardiogram) monitoring
  * continuous blood pressure monitoring through an arterial line; it can also be used to easily draw blood samples from the patient, which is often required many times a day; the arterial line is a smallish venous cannula inserted into the radial, brachial or femoral artery; the arterial line is NOT used for giving the patient fluids or medications! It's for measuring thing and taking samples, not putting anything IN.
  * regular blood pressure cuff that inflates within a set interval IF an arterial line is not used
  * oxygen saturation monitoring, ie the pulse ox ie that clip in the finger (or in the earlobe)
  * at least one regular intravenous cannulas (IVs); several, if there is no central line; the problem with these is that you need many of them if you're giving the patient lots of fluids and medications, and some meds and intravenous electrolyte solutions and intravenous nutrition stuff irritates smaller veins
  * a central line (CVC), which is a larger intravenous cannula inserted usually into the external jugular, the subclavian or the femoral vein; central lines are handy because they can take a lot of stuff (they can have many holes ie lumens, allowing lots and lots of different things to be administered simultaneously), these bigger veins don't get as irritated as the smaller ones from strong electrolyte solutions, certains meds and intravenous nutrition, you can use a central line to monitor things such as central venous pressure and if it's a big line (think on the lines of a drinking straw) even cooler things such as a Swan-Ganz catheter (aka pulmonary artery catheter, used in more detailed monitoring of  the patient's heart) can be inserted
  * urine catheter ie Foley to monitor urine output (very very important at the ITU)
  * nasogastric or orogastric tube ie that disgusting contraption that goes to your stomach; the needs for this is based on the fact that patients' guts might be malfunctioning due to severe illness, or they might have stuff in their stomachs that's at risk of ending up in their lungs, so all that needs to be drained out; the NGT can also be used to administer nutrition (see below why this is a good idea)



[Here you can see Sherlock](http://kissthemgoodbye.net/sherlock/albums/s3/e03/Sherlock_S03E03_1080p_kissthemgoodbye_net_2411.jpg) with a three-lead ECG, a regular BP cuff, a large-bore regular IV in the crook of his left elbow and a central line. [Here's a better glimpse](http://kissthemgoodbye.net/sherlock/albums/s3/e03/Sherlock_S03E03_1080p_kissthemgoodbye_net_2407.jpg) at his gorgeous central line with three lumens.

Usually the right side is favoured for inserting these lines since it's a bit safer (a thing called the thoracic duct in located on the left side and it has no right-side pair). They may have selected the right side bc he was being operated on on the opposide side or the vascular anatomy was not favourable there. The central line was inserted soon after he was brought into the hospital, since we can see it in the resuscitation scene. I was left wondering why they'd insert a three-lumen one instead of a large one designed for quick fluid resuscitation. It's not easy to insert a central line during resuscitation, and he already had two regular IVs in place at that time. Artistic licence?

 

Additional things a patient at an ITU might have, depending on their particular illness:

  * pleural drain or drains to get fluid, blood or air out of the pleural cavity; this is often needed in chest injuries, a spontaneous pneumothorax or severe pneumonia
  * other drains, for instance going into the abdominal cavity
  * intracerebral pressure monitoring (a sort of a bolt in the head through which a sensor monitors the pressure in the area of the brain it has been inserted into; see the brain injury section for a more detailed explanation)
  * epidural catheter to treat pain or some other continuous nerve block catheter (epidural is the commonest)
  * wound dressings and continuous wound suction devices (I'm not kidding)
  * pump socks to prevent blood clots in patients who cannot be given blood thinners
  * dialysis cannula (which is a large central line)



 


	7. Monitoring and imaging an ITU patient

**Stuff you might see on a patient monitor**

[Have a look at ](https://www.fanfiction.net/s/9374069/1/Reliably-Informed)[this picture](https://qph.ec.quoracdn.net/main-qimg-018ca07ea978f3b6e761a9cf3cfd2fe1-c). Explanation for what you're seeing: 

  * Green = ECG (heart rhythm, heart rate, monitoring for certain changes in the ECG that might point to the heart muscle suffering from lack of oxygen or some other acute issues)
  * Red = arterial line; shows blood pressure and the arterial pressure curve
  * Yellow = pulmonary artery pressure (this is from a pulmonary artery catheter which not nearly all ITU patients will have, see above the section on cannulas and hoses and sundry)
  * Turquoise = oxygen saturation with its curve; this comes from the pulse oximeter
  * White = respiratory rate and curve; this is how often the patient is breathing; the source can vary or this might only be seen on the respirator monitor, which is almost always a separate one
  * Pink = the latest regular BP cuff measurement 



If the patient has some extra monitor such as an ICP meter, such devices often have their own small monitors.

 

**What does a respirator and its monitor look like?**

There's huge variation between models, but [here's an example](https://www.draeger.com/Products/Image/evita_v500_MT-1895-2008.jpg).

In general you will see at least three curves: the pressure curve, the volume curve and a carbon dioxide curve. Numerical values for airway pressures (pressures inside the hose system connected to the patient), "inhalation sizes" and other such parametres will be shown, as well as the mode in which the machine is functioning (for instance, pressure support for the patient's own breathing, or a solely machine-operated cycle).

 

**Imaging at the ITU**

Imaging means X-rays, MRIs, CTs… 

Chest X-rays and some other simple X-rays can usually be taken at the ITU with portable machines. It's when the patient needs a computer tomography (uses radiation, fast) or an MRI (no radiation, slow, nothing metallic can be taken into the MRI suite which can be a hassle with ITU patients) when thought needs to be put into how to move a patient hooked up to a million infusor pumps and the respirator. See below for details.

If one needs quick info on what's going around in the patient's head, a CT is usually first-line imaging. When looking for some very particular things, an MRI might be considered but, as stated above, it's much slower. Regular X-rays are never taken of patients' head anymore, not really.

Bedside ultrasound is becoming very common in intensive care and emergency medicine, even outside the hospital. It can be used, among other things, to look for bleeding inside the abdominal cavity or to check if there's a pneumothorax. Ultrasound is also a very helpful tool for putting in cannulas and doing nerve blocks. John shows some aptitude with this approach in [The Road of Bones](http://archiveofourown.org/works/4527585).

 

**Who interprets all these MRIs and X-rays...?**

Intensivists and most other docs can interpret basic X-rays and some CTs and do certain types of diagnostic ultrasound exams if they've had training for it, but for a more detailed analysis of more complex imaging you need a radiologist (a doctor specialising in imaging) who will frown at those slides for a while and then type up a report that is full of stuff nobody else would even have thought to look for.   
  


**What's angiography?**

In short, it's when contrast dye is injected into a patient to visualise their blood vessels and to do procedures inside those vessels. A percutaneous balloon angioplasty (PTCA), often followed by inserting a stent (a hollow tube-like thing that keeps the vessel open) is a common procedure to be done in the coronary arteries of the heart if a length of an artery has gotten blocked. Brain aneurysms can be filled with coils or fixed with flow diverter stents. Some of these procedures can be done while the patient is awake and sometimes it's best to put them under general anaesthesia.

Interventional radiologists can do other impressive stuff, too, such as putting in stents into internal organs and to take MRI- or CT-guided tissue biopsies.


	8. "It's just a flesh wound" - injuries and illnesses

**What's sepsis?** (with this section a helpful reader supplied some of the links and info)

A good website for up-to-date information: <https://emcrit.org/isepsis/isepsis-introduction-isepsis-website/>

The current/new definition of sepsis is _'A life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs_.'- i.e. it is not generally due to infection overwhelming the body's immune system but rather due to an over-enthusiastic immune response to a significant infection.

The patients who end up on the ICU are generally those with septic shock (ie the cardiovascular system has collapsed or is threatening to collapse) and that is why SIRS has been replaced with the so-called qSOFA score with the aim of identifying this subgroup early. It is generally hypotension unresponsive to inotropes (ie medications that "whip" the heart into more action) that leads to sepsis requiring intensive care. Respiratory compromise or a low GCS score are less common reasons.

Sepsis can start from a local infection, such as an abscess, but it can develop without showing any localised signs. Sepsis can develop slowly, or very quickly. Some of the organ damage in sepsis is due to the body's own immune system going haywire, some is due to the microbe's actions.

Sepsis can wreck many organ systems. It can mess with the kidneys, put a big strain on the heart, cause issues with breathing, alter the patient's perception and consciousness (a sort of an acute illness brain dysfunction) and even confuse the blood clotting system, causing clots or bleeds or _both_.

Some sepsis patients can be managed in less-than intensive care, if their breathing is uncompromised and their level of consciousness acceptable. Severe sepsis, however, is often characterised by dysfunction in many organ systems and needs to be managed at an ITU. Sepsis can and will often kill. The [Surviving Sepsis Campaign website](http://www.survivingsepsis.org/Guidelines/Pages/default.aspx) offers a lot of good, up-to-date pointers on sepsis management.

[Raison D'Etre](http://archiveofourown.org/works/1141383) by AmphigoricSymphony & DemonicSymphony is a heart-wrenching, medically flabbergastingly sound tale of Sherlock developing intra-abdominal origin sepsis after Mary shot him in HLV.

 

**What do you suppose happened to Sherlock when he was shot?**

There's a [brilliant meta](http://archiveofourown.org/works/1235479?view_full_work=true) done on this. Also, go read Emma221b's [Fratros, Eros and Agape](http://archiveofourown.org/works/1146328/chapters/2321535), including its comments section. 


	9. What happens after intensive care?

**Where do patients go from the ITU?**

Almost _never_ straight home. They go to a regular ward, or something like an HDU (High-Dependency Unit), which is sort of a stepdown from the ITU. Patients can be hooked up to monitors there, but they won't be on a respirator or require anything other equally intensive. Many specialties have their own HDU-type units such a stroke units and coronary care units (CCUs). The acute medical ward Sherlock is admitted to in [On The Rack](http://archiveofourown.org/works/8589025) is a good example of an HDU-type placement. Here's [a neat explanation](http://careers.bmj.com/careers/advice/view-article.html?id=815) by the British Medical Journal of the differences between an ITU and and HDU.

Types of HDUs: cardiac, neurological (often called a <i>stroke unit</i>, although other kinds of ailments might be present there, too), surgical, trauma, paediatric, respiratory. 

If a patient does not regain consciousness but can breathe on their own, they might be given a tracheostomy and moved to a regular ward or hospice.

   

**What does post-intensive care syndrome mean?**

For some patients, recovery from the acute illness that landed them at the ITU does not mean that their troubles are over. An entity called post-intensive care syndrome can mean many things, but the major features tend to me listed as weakness and nerve function problems, cognitive difficulties and mental health problems. Related terms include [critical illness myopathy and critical illness polyneuropathy](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3145308/).   

[Here's a good general introduction](http://www.myicucare.org/Thrive/Pages/Post-intensive-Care-Syndrome.aspx) to the syndrome. [Another article](https://www.ahcmedia.com/articles/134820-post-intensive-care-syndrome-risk-factors-and-prevention-strategies) discusses risks and grass roots preventive strategies.

In the story I co-authored with 7PercentSolution, [On the Rack](http://archiveofourown.org/works/8589025), Sherlock is suffering from post-intensive care syndrome along with a relapse of severe depression.


	10. Surgical procedures and more exotic treatments at the ITU

**What sorts of (dramatic emergency) procedures might be done at an ITU?**

ITUs are not often very far from operating room units, so anything major that needs doing is best done at a well-equipped OR. Sometimes the procedures required are so minor that they are best carried out where the patient already is, tucked into an ITU bed. 

Everyday normal things that will happen at an ITU are insertions of chest/pleural drains, intubations, insertions of different kinds of IVs and central lines, insertions of any of the stuff I listed as belonging in the basic set of hoses and cannulas every ITU patient tends to get, wound treatments, suctioning of inserted hoses, creating tracheostomies.

When shit hits the fan, one might have to do a quick chest drain, drain a cardiac tamponade (that's when the pouch surrounding the heart fills with something which needs to be drained before the heart runs out of space to contract in) with a needle or do a resternotomy on a patient who has recently had a heart operation. That means opening up the surgical wound on their sternum to relieve pressure from the heart pouch (pericardium) or to shove your finger where you see a bleed (not kidding). You might also need to intubate someone in a hurry, or to do an emergency cricothyrotomy (ie make an emergency airway through the patient's neck when their upper airways have gotten catastrophically blocked).

In Emma221b's [Fratros, Eros And Agape](http://archiveofourown.org/works/1146328/chapters/2321535), Sherlock had a cardiac tamponade (among a pile of other acute problems related to the shooting).

 

**Some more exotic treatments ITU patients might need**

I'm going to give a short overview of both common and uncommon supportive treatments available at ITUs. If you're going to describe any of these in detail, get a medical consultant for your fic or you'd better otherwise know what you're doing…

Dialysis means taking over the job of the kidneys to remove toxic substances and products of metabolism from the body. Poison, toxins, certain medications and infections such as sepsis can cause kidney failure. As a matter of fact, the kidneys might go bust due to [a long list of reasons](http://www.mayoclinic.org/diseases-conditions/kidney-failure/basics/causes/con-20024029). 

If there's a blockage in the lower end of the system such as a stone preventing urine from getting out, that should be fixed by circumventing the flow or taking the blockage out. If the reason for kidney failure isn't in the kidneys or elsewhere in the urinary system, then that needs to be addressed. Running a marathon (ie getting dehydrated and muscles taking a banging, releasing substances to the blood which are harmful to the kidneys) and then swallowing a bunch of common, nonsteroidal painkillers might give even a healthy person acute kidney failure.

Dialysis requires a large cannula inserted into a vein (usually a temporary one). It's available at nearly all ITUs. Kidney failure was mentioned in The Lying Detective (it often does resolve just with observation when the patient's health improves otherwise at the ITU), and it's what was worrying the doctors in Harmless Things.

MARS means Molecular Adsorbent Recirculating System. It's a bit like dialysis, but for the liver. The liver can go into acute failure for many reasons, the most common being poisons and toxins, drug/medication overdose (paracetamol/acetaminophen is a very potent liver wrecker even at relatively low doses), alcohol abuse and sepsis. MARS is not nearly as widely available as dialysis.

Hyperbaric oxygen treatment is not available at all ITUs. It can be used to treat severe tissue infections such as gas gangrene and necrotising fasciitis, the bends ie decompression sickness in divers, poorly healing wounds, acute traumatic ischaemic injuries such as crush injuries, air or gas embolism, carbon monoxide poisoning. Taking a patient who's in a respirator to get this treatment is hard work; a lot of the usual things we use in patient care are too flammable or the air inside them could expand too much (even pillows!).

ECMO means extracorporeal membrane oxygenation. If a patient's lungs or heart have completely failed, they can be helped or bypassed with this treatment, at least for a while. It this need arises, it means that the patient truly is at immediate risk of death. Definitely not available everywhere. 

Intra-arterial balloon pump. If a patient's left ventricle is failing or needs support after cardiac surgery, this device can be inserted to help pump blood forward in the aorta. Not available everywhere. There are other assist devices that can help a patient survive while they're on a cardiac transplant list, and some of them allow the patient to stay at home. Whitchry's story [Reliably Informed](https://www.fanfiction.net/s/9374069/1/Reliably-Informed) deals with that.

 

**Author's Note:**

> I'd like to see this as a work-in-progress. Feel free to use the comments section to ask whatever comes to mind or to suggest new sections to be added. Many commenters have already contributed to the contents - thank you for that!


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